Airway

Question 1

How do you make the decision to intubate?

Answer 1

1. Failure to maintain or protect the airway (example: Can’t handle gastric and oral secretions, aLOC)
2. Failure to ventilate or oxygenate
3. Patient’s anticipated clinical course and likelihood of deterioration (Example: multiple trauma, open#, neck trauma, burns)

Question 2

How to you assess an airway? / What are the predictors of difficult intubation?

Answer 2

LEMON
L. Look for gestalt signs (i.e. underbite, facial trauma, neck shape/size)
E. Evaluate the 3-3-2 rule (3 fingers = mouth opening, 3 fingers = length of mandible, 2 fingers = thyromental distance)
M. Mallampati score (Mallampati I = easy; Mallampati IV = challenging)
O. Obstruction or obesity (examples: epiglottitis, ludwig’s angina, head & neck cancer, neck hematoma, polyps etc.)
N. Neck mobility (examples: Spondylosis, Rheumatoid Arthritis, etc.)

Question 3

What are predictors of difficult bag valve mask ventilation?

Answer 3

MOANS
M. Mask seal (examples: beard, cachectic face)
O. Obstruction or obesity
A. Age > 55
N. No teeth
S. Stiffness to ventilate (examples: Asthma, COPD, pregnancy)

Question 4

What are the predictors of difficult LMA insertion?

Answer 4

RODS
R. restricted mouth opening
O. Obstruction or obesity
D. Distorted anatomy
S. Stiffness to ventilate (examples: Asthma, COPD, pregnancy)

Question 5

What are the predictors of a difficult surgical airway?

Answer 5

SMART
S. Surgery (previous to area)
M. Mass (abscess, hematoma)
A. Access/anatomy problems (obesity, edema)
R. Radiation (previous to area)
T. Tumor

Question 6

How do you confirm ETT placement?

Answer 6

Gold Standard: EtCO2 (assessed via 6 manual breaths)
Back up: aspiration, bougie, USS
Secondary Means: physical exam findings, oximetry, radiography

Question 7

How to set up for and perform a RSI?

Answer 7

7Ps
P - Preparation (staff, space and stuff set up including RSI and emergency drugs drawn up, ETT equipment, back up plan out, monitoring, 2x IVC)
P - Pre-oxygenation (100% oxygen for 3mins of normal TV breathing or 8 vital capacity breaths with HiFlow = 6-8 min of safe apnea; decreased in children, obesity, critical illness. No bagging in RSI)
P - Pretreatment
P - Paralysis with induction (rapid IV push of sedative followed immediately by NMBA)
P - Positioning (sniffing the morning air - cervical spine extension and head elevation; face parallel to ceiling; ramping in obesity to get anterior tragus in line with sternal notch)
P - Placement of tube
P - Post-Intubation Management (confirm ETT placement, CXR, ongoing infusions, attach to mechanical ventilator)

Question 8

Other methods of intubation:

Answer 8

1. Delayed Sequence Intubation (DSI) (maximize preoxygenation in agitation/delirium/confusion by providing a procedural sedation dose of ketamine)
2. Blind Nasotracheal intubation (essentially not used)
3. Awake Oral Intubation (topical anaesthetic and sedative used to manage difficult airway without NMBA; ketamine v. dexmedetomidine +/- BNZ are often used as sedative
4. Oral Intubation without pharmacology agents AKA ‘Crash Airway’ (may require 2mg/kg dose of succinylcholine)